Friday, August 31, 2007

Two minutes later, someone with the username Gscshoyru, whose Wikipedia profile describes him as a “recent changes patroller,” added the information back to the entry.

Jeffrey Light, who runs the one-man nonprofit Patients not Patents used Wikipedia Scanner to see what the drug industry had been up to on Wikipedia. He made a press release on this subject, you can download this press release from the article on HealthBlog from the Wall Street Journal.

Wikipedia Scanner -- the brainchild of Cal Tech computation and neural-systems graduate student Virgil Griffith.This software offers users a searchable database that ties millions of anonymous Wikipedia edits to organizations where those edits apparently originated, by cross-referencing the edits with data on who owns the associated block of internet IP addresses.

This is the second drug company that was discovered doing this. The other company was AstraZeneca for their drug seroquel. Would like to use WikiScanner on some other drug companies as well, but it takes a lot of time.

Thursday, August 30, 2007

50 to 60 % of patients with a depressive disorder fail to respond to their first antidepressant. These rates increase in clinical practice setting to 65 to 85%. Estimates of TRD prevalence varies greatly depending on treatment setting. The lowest TRD prevalence is in primary care and progressevily higher rates occur in outpatient psychiatric settings, inpatients settings and academic tertiairy setting.

Compared to non-TRD, TRD patients have been reported to have significantly higher outpatient medical costs, and to be approximately twice as likely to be hospitalized, either medically or psychiatrically

What is Treatment-Resistant Depression?An inadequate response to an adequate course of treatment in a patient meeting criteria for major depressive disorder. Treatment is usually antidepresssants. Depression is not bipolar depression. This diagnoses needs a different approach. An adequate course is a course of an adequate dosage of the antidepressant for at least 6 weeks. This has been operationalized in criteria for different stages of TRD:

Stage 1. Failure of an adequate trial of 1 class of antidepressant

Stage 2. Failure of adequate trials of 2 distinctly different classes of antidepressants

Stage 3. Stage 2 plus failure of a third class of antidepressant, including a tricyclic antidepressant

149 patients (50%) were included in the 4-step algorithm. Of the 56 patients who were excluded fromstep 1 because of proven refractoriness to antidepressants during the index episode, 54 were enrolled directly into step 3 of the algorithm. Only 4 (7%) of these 54 patients had received lithium addition. Ten patients needed immediate ECT.

At the end of the algorithm, 129 (87%) of 149 patients achieved response. Complete remission was achieved by 89 of 149 (60%) patients. Three patients switched into hypomania during the algorithm: 2 receiving a combination of imipramine and lithium and 1 patient receiving phenelzine. These patients were considered both as responders and remitters. Overall dropout of the algorithm amounted to 24 (16%) of 149 patients. When including patients who entered the algorithm at step 3 (treatment with a nonselective MAOI) the figures are as follows: 165 (81%) of 203 responded during the algorithm and 101 (50%) achieved remission. Overall dropout, including the 54 additional patients, was 30 of 203, i.e., 15%.

These results emphasizes the importance of persisting with stepwise antidepressant treatment in non-responders to the first antidepressant. Important is to note that this trial was done on a depression unit in a academic/tertiary centre.

Wednesday, August 29, 2007

Your genes probably predict response to ECT more accurate then any clinical variable.

Genes, enzymes and neurotransmittersGenes are located on DNA in the nucleus of the cells in your body. You usually have two genes on each arm of a chromosome ( one from dad and one from mum). If the two genes are identical it's called that they are homozygote, if they are different it is heterozygote. Genes are read by other cell nucleus material (RNA) which starts a sequence to produce proteins. The most important proteins being enzymes. Enzymes are needed for the metabolism of neurotransmitters among others. Neurotransmitters are chemicals that are used to relay, amplify and modulate electrical signals between a neuron and another cell in the brain. Catechol-O-MethylTransferase (COMT) is a major enzyme in the brain for the metabolism of dopamine, a neurotransmitter. A polymorphism in the gene coding for COMT results in substantial effects, with a homozygote allele variant leading to a three to fourfold reduction in enzymatic activity compared to the other homozygote variant. In general, polymorphism describes multiple possible states for a single property. This single property being a single amino-acid sequence in the allele for COMT. The presence of Met/Met and Met/Val or Val/Met results in a much lower activity of COMT than Val/Val (high activity).

Low Dopamine concentration in Prefrontal CortexThe high genotype of COMT was associated with better treatment response to ECT than low allele containing genotypes. Since high genotype results in a high activity of COMT and a low dopamine concentration in the prefrontal cortex we can assume that low dopaminergic activity in the prefrontal cortex is associated with a better response to ECT.

This was shown in 119 treatment-refractory depressed patients admitted consecutively for electroconvulsive therapy (ECT). The effect of clinical variables also related to a better response to ECT were studied using univariate analysis of variance. These covariates: higher illness severity, age, age at onset, sex and the number of ECT treatment did not affect the treatment response.

Not all studies with COMT polymorphism and response to antidepressants found an association between this polymorphism and response. COMT also plays a role in the metabolism of norepinephrine, another important neurotransmitter in the brain. Other limitations of this study are a small patient sample and the concomitant use of psychotropic drugs during ECT. ECT itself was properly performed.

Biological variables predicting responseA very nice publication in a new field of research. Important topic predicting response in a patient with biological variables.

Tuesday, August 28, 2007

Most scientist know PubMed. It is a powerfull search engine for scientific literature. It is a bit dull, not so very geeky. In comes Gopubmed. It has the power of PubMed and then some more. It has some nice graphic as well as usability improvements compared to the original PubMed. The results page is divided into two sections. On the right hand side the latest 1000 PubMed citations that match your search term. But the fun is on the top of the right side:

If you click the “show statistics for these 1000 articles” you get the citations summarized on the basis of a number of variables such as top authors, journals, cities, countries and years. This is pretty nifty if you want to get an idea of who is publishing most in the area, where the publications are coming from and what journals are publishing that kind of content. Some examples of the statistical analyses are shown below. Another cool thing is you can click on names, journal and locations to get those specific citations.

On PsychPlash these add ons are illustrated with graphics from gopubmed.

On the left-hand side :1. Gopubmed annotates the resulting citations with GO and MeSH terms2. Content Filters are extremely useful in helping you answer specific questions relating to your initial search query3. The Document Filters are the same as the citation statistics mentioned in the blockquote above4. The site has an extensive help function.

Try electroconvulsive therapy. The next picture is the top 20 cities and countries with this search term. Is that The Netherlands on place 6?

Monday, August 27, 2007

is conducting a new survey about medblogs. If you're a health care blogger do the survey

WHY WE NEED YOUR HELP

We can't continue to get a better understanding of the healthcare blogosphere without your help. We need as many healthcare bloggers (those devoting at least 30% of their blogging time to healthcare) to take the survey so that we can make valid conclusions about the size and shape of this growing part of the global blogging community.

In the recent past I was interested in search engines. You have different kind of search engines, the most famous being Google. Google is a traditional search engine.

A meta-search engine is a search engine that sends user requests to several other search engines and/or databases and returns the results from each one. Meta search enables users to enter search criteria once and access several search engines simultaneously. Since it is hard to catalogue the entire web, the idea is that by searching multiple search engines you are able to search more of the web in less time and do it with only one click. The ease of use and high probability of finding the desired page(s) make metasearch engines popular with those who are willing to weed through the lists of irrelevant 'matches'. Another use is to get at least some results when no result had been obtained with traditional search engines.

Sunday, August 26, 2007

Only 1 in 10 medical clinical professors are women in the United Kingdom (UK). No female professor was employed in 6 medical schools. The newer medical schools had a better gender balance than some of the more established schools.For the lower ranks in medical academia these numbers are somewhat higher but still much lower than for men.In FTEs lecturers in 2005: 36% were women, senior lecturers and readers: 25% were women. In 2005 there were a total of 3365 clinical academics, of whom 21% were women. There was a wide range in the number of professors per speciality; the majority were physicians. The percentage of women professors ranged from 0% (in occupational medicine) to 20% and over (e.g. in radiology, general practice). This gender difference remained relatively constant between 2004 and 2005.

These results were published in Medical Education. This study was needed since data available about gender-specific workforce in clinical academics were limited. These data are reported in order to allow comparison over time.

Conclusions Over the past four decades, the proportion of women among both first and senior physician-authors of original research in the United States has significantly increased. Nevertheless, women still compose a minority of the authors of original research and guest editorials in the journals studied.

The United States of America is a favourable exception when it comes to enhancing the careers of women in clinical academics. In Europe conditions are far worse on academic careers for women.

Women and Science in The NetherlandsIn The Netherlands 400 female professors are needed in the coming years in order to answer the European agreements in 2010.

What hinders academic careers for women?1. Lack of role models and support for female staff2. Family/carer commitments3. Lack of network because there aren't many females. Men seem to help each other more to get in key positions4. High levels of teaching, administrative and pastoral care loads for women. These tasks are not recognised as much as research output5. Discrimination. Part time work in women is seen as lack of commitment6. Generational and other issues. A large number of baby boomers in senior positions are not moving on.

Saturday, August 25, 2007

" If you can't take good care of yourself, how can you take care off your patients?", this is what I tell my residents at least once during their training. 60 to 80 working hours a week is not taking good care of yourself nor your patients.

You can't perform well with this schedule, you can't be patient, you will make mistakes, especially when working long hours at a stretch. Pilots know that and doctors should as well. Tutors should be role models for residents and teach them that they are responsible for their own performance. They should discourage the macho attitude of doctors being able to work long hours, it being part of their job. It is in contempt of their responsibilities and patients entrusted in their care.

Patient-doctor interactionAnother important topic is how a doctor can remain sensitive to the demands of his or her patients. In other words how can a doctor be empathic without loosing his professional distance necessary for good judgment and decision making. Avoiding excessive emotional involvement which can harm his care for the patient, obscure his clinical judgment.

In order to introduce medical students to this responsibility the book: The case of Dr Sachs and the film La maladie de Sachsis recommended by Josep-Eladi Baños from Barcelona, Spain. He wrote a letter to the editor of one of my favorite journals: Medical Education.In this book and film a French doctor practising in a rural area has a "disease".

The symptoms of his disease involve excessive worry about his work of caring for other people, to a point where he neglects to care for himself and devotes most of his time to doctoring.

The book is especially revealing about how a doctor might feel when he is treated as a patient and how he considers the disease from the perspective of a patient

Conclusions

The author of the letter to the editor recommends that it is easier to discuss the films than the literary works, the focus being the doctor-patient relationship.The two suggested books and films are excellent teaching material for medical students on the topic off patient-doctor relationship.

Friday, August 24, 2007

As a clinician I always wondered why some abused patients had more trouble recovering from their psychiatric illness than others. This article about the gene environment interaction in Psychiatry clarifies some of the variations in outcome. This article explains in relatively accessible written prose some of the experiments that have influenced our thinking about gene and environment interactions in relation to psychiatry. It is written by David D. Olds, M.D. Columbia College of Physicians and Surgeons New York.He teaches clinical psychiatry and psychoanalysis at Columbia University and is an editor of the journal Neuro-Psychoanalysis. He has written often on the relationship between neuroscience and psychotherapy. Wanted to comment on his article. Curious how psychotherapy with sexually and or physically abused patients influences our brains or perhaps even genes. Maybe a topic for a future article on this blog.

Thursday, August 23, 2007

No severe cognitive side effects of ECT used on adolescents could be demonstrated. ECT in adults causes memory complaints, retrograde and anterograde amnesia. The tests used in trials with adolescents are limited in measuring these side effects. Moreover there are no prospective studies on this subject with adolescents and the studies discussed have a small number of subjects with possible lack of statistical power.

Publications about ECT and side effects in adolescentsSo far I was able to find four articles about cognitive side effects of ECT in adolescents. They belonged to two different research groups.From the department of psychiatry of the university of Michigan there is a study in which 5 of 11 adolescents treated with ECT were tested both before and 1-5 days after the last ECT. The neuropsychological tests revealed a significant decline in attention, concentration and long-term memory search. In another publication by this group they collected retrospective data resulting from clinical care with naturalistic follow up of 16 adolescents treated with ECT for mood disorder. Cognitive tests administered before ECT were compared with results at 7 days following the last treatment as well as another testing at 8 months after the last treatment.

Cognitive side effects 1

Testing directly after ECT and compared to the test before ECT yielded significant impairments of concentration, attention, verbal- and visual delayed recall, and verbal fluency. A complete recovery of these functions was noted at the second post-ECT testing. There were no impairments of motor strength and executive processing, even during the early period post ECT.

These studies had little focus on memory disturbances with ECT in adolescents.The other group from Paris, France focused on memory function. 20 adolescent patients treated with ECT during the period 1987-1996 were contacted for follow up. For various reasons only 10 could be included. Another 10 subjects comparable for sex, age, date and place of hospitalization and diagnosis were considered as a control group.All subjects were given a battery of clinical and cognitive evaluations. The most important being the Wechsler Memory Scale and California Verbal Learning test , which assesses anterograde amnesia and verbal learning as well as Squire's Subjective Memory Questionnaire for subjective memory complaints.

Cognitive side effects 2

The ECT group did not differ significantly on all cognitive tests at an average of 3.5 years after the last ECT compared to the matched control group.

Lousy testsTrouble is that all these tests are of no use for the memory effects of ECT at all. The Wechsler Memory test is like the original Wechsler Memory Scale, and provides only a rough estimate of overall memory functioning. The multidimensional index scores have not been shown effective in describing the nature or the pattern of memory deficits. The California Verbal Learning Test (CVLT) is a popular clinical and research test that claims to measure key constructs in cognitive psychology such as repetition learning, serial position effects, semantic organization, intrusion, and proactive inteference.

In an earlier article the lack of proper memory tests for testing retrograde and anterograde amnesia in adults treated with ECT is mentioned.

Wednesday, August 22, 2007

I read the first edition of this book while on holiday in France. We were cross-country skiing. Not that the weather was bad or the company boring but this book is very informative and easy to read. Read all the other editions as well. For me it is the most narrative book about ECT with a critical appraisal of all the scientific literature. Obviously written by an experienced and good clinician.This book is reviewed on Medical Heaven, I couldn't have done a better job.

A list of medical blogs based on a algorithm with the number of comments, posts, feed readers, incoming links. You can see the widget about it in my sidebar.Here is a discussion about rating medical blogs.

The researchers decline naming certain cities but they revealed one trend: use of methadone and methamphetamine (a prescription opiate withdrawal aid and speed) remained constant over 24 days in these cities, but cocaine consumption routinely spiked on the weekends.A method of taking a small sample of incoming sewage at a water treatment plant is developed. This method can extract the record of local drug useEnvironmental analytical chemist Jennifer Field of Oregon State University and her colleagues, using an automated system to test small samples automatically collected at wastewater treatment plants over a 24-hour period. Solids are centrifuged out and the sewage sample is then chemically separated in various compounds of interest chemically. By measuring the relative mass of the various residual chemicals, the chemists can then identify what specific drugs have been recently used in that community.The technique might help communities determine where to apply law enforcement or track the success of targeted drug-use prevention efforts.This article about sampling for local drug use appeared on Scientific American.I remember an article in a Dutch newspaper mentioning that with a comparable method it has been shown that in Spain the abuse of cocaine is the highest of Europe.

Tuesday, August 21, 2007

Leon Rosenberg, a former dean of medicine at Yale University, had just attempted suicide by overdose. He was admitted to hospital and prescribed electroconvulsive therapy, or ECT.

This is the start of an excellent article by Michael Evans an associate professor at the University of Toronto and staff physician at Toronto Western Hospital.This article also discusses some other myths, for instance about depression:

Those on the outside still see it as not really a disease but a weakness. Those on the inside see it as a chronic disease like any other, but with a twist.

Or this one about suicide, one of the complications of depression:

"Heart attack victims are consoled ('Isn't it a pity?'); suicide victims are cursed ('How could he?')."

About ECT:

We discount a therapy that has proven effectiveness because of its image, yet every day embrace unproven therapies that have benefited from a public-relations makeover.

To my opinion the most nuanced view on side-effects of ECT:

Memory loss seems the side effect of most concern to patients. With current ECT, it is usually transient, but any unauthorized withdrawal from the memory bank is a travesty. The medical community has occasionally shown insensitivity to this, but researchers are now attempting to better delineate the cause and effect.

Homeopathy claims that their pills go with your individual symptoms of depression and personality. Ignatius for instances cures "depression" after a loved one's death. Ignatius is made from the ignatius bean. Ignatius beans were frequently used as a cheap strychnine substitute for Strychnos nux vomica, strychnine. Ignatius beans are used chiefly as a homeopathic remedy, administered in very small doses because of extreme toxicity. Improper dosage-internal consumption of as little as a fraction of an ounce - can result in muscle spasms and painful convulsions and even death by asphyxiation. Not only are homeopathic "medicines" usually expensive, their efficacy is not scientifically tested. Recently there has been a debate about depression in the British Medical Journal. Gordon Parker defended the opinion that depression is over diagnosed. At first I didn't want to support his point of view, but calling mourning a depression as is done in this article promoting homeopathy for treating depression makes me uncertain again.

Sunday, August 19, 2007

In medicine as well as in other fields pdf files are widely used. A free reader from adobe is available. But if you need to do other things with the pdf files please go and see this article on lifehacker.com.It has many suggestions for both Mac and Windows users. The most important which I use a lot is:1. merge pdf files2. edit pdf files3. save any file as pdf file.

Patients in psychiatry have complicated medical histories. Patients with Bipolar disorder are one of them. Patients often have multiple episodes with different medication schedules, helpful or not. Life Charts are used for diagnostic and therapeutic purposes with these patients. Other mental illnesses also have a fluctuating course with partial or complete remission. A recent article on medgadget.com discussed TimelineMaker, a software package specifically designed to create clean looking time lines.

You quickly enter a series of events and details like time and place, click the button that generates the chart, and you automatically get a simple timeline. From here one can add details to the chart, move things around, add notes, and generally change the look and feel of the timeline.

Looks perfect to me for reconstructing patient histories, you can download a trial version at TimeLineMaker.Here an example from the software maker:

Friday, August 17, 2007

Dr Shock is in Scotland for a few days. This afternoon he had the pleasure of sitting in a Sir Winston Churchill chair, while sipping his afternoon tea. The hotel owning this chair is on the picture. The chair is made out of timbers from Blenheim Palace, the place were Sir Winston Churchill was born. The manufacturer also used copper left over from material from world war two.Above the chair there was a certificate. Under the seat of the chair there was a sigar humidor. Most convenient, room for three Cuban sigars. Very solid made and comfortable.Price 3250,- pounds.

Thursday, August 16, 2007

AstraZeneca deleted references to claims that taking Seroquel carries a risk for teenagers: they will be more likely thinking about harming or killing themselves when taking this drug. The deleter was a user of a computer shown to be registered to the drug company. The FDA proposed that makers of antidepressants including AstraZeneca update their text to include warnings over increased risk of suicidal thinking in young adults.Dr Shock read this while in Scotland in The Times.Wikipedia Scanner -- the brainchild of Cal Tech computation and neural-systems graduate student Virgil Griffith -- offers users a searchable database that ties millions of anonymous Wikipedia edits to organizations where those edits apparently originated, by cross-referencing the edits with data on who owns the associated block of internet IP addresses. This program cannot identify the individual behind the computer but it can identify the computer and the network it is on.Other misuse of Wipipedia is on Godlike productions.Would like to find some more pharmaceutical companies but the site is down, to many interested readers or drug companies again?

In 1860, Elizabeth Packard, who differed with the theology of her clergyman husband, was forcibly placed in an Illinois state hospital. She remained there for 3 years. At that time, Illinois law stated that "married" women could be hospitalized at a husband's request without the evidence required in other cases. Want to know how this ended?

The Question of Patient Restraint in 1900?

Women were not welcomed into the medical profession during the first half of the 19th century. Many arguments against women becoming physicians were physiological and neurological: would the education and training required make a woman unfit for her "primary duty," childbirth? And was rest (physical and mental) necessary during menstruation? Want to know when this was abolished?

American asylums were influenced by visits of their superintendents and others to European hospitals. Want to know about these developments?

Wednesday, August 15, 2007

Dr Shock is very honoured to be in the top 25 medblogs on number 13. My lucky number as well. The dutch website is called medgadget.nlThis blog also has en English version, with a ranking for English medical weblogs on which Dr Shock doesnot appear......yet.But never mind, I write in English at least I try to write proper English.

Medgadget.nl:

I have been a big fan of Medgadget.com for a while now. You can read more about the founders at Planet.nl (dutch). That is why I thought it would be great to introduce a dutch alternative. At this site I will present the newest medical gadgets, medical technology and research. Now and then I will shine some philosophical light on some of the issues presented on this website.

Free Medical Journals was launched in late February 2000, days before the inflation of the Internet bubble. Within a year, it had 15,000 visitors per day. In early 2007, these figures stabilized to around 7,000 daily visitors.

FMJ is a simplistic website: it only produces a list of free journals.Most articles from the journals listed at FMJ are freely available one to 6 months after publication. But there are also really free medical journals even for psychiatry

Tuesday, August 14, 2007

Hypoperfusion of parts of the brain in depressive disorder largely normalizes after response to antidepressants. Perfusion changes after response to electroconvulsive therapy (ECT) follows a different course. This interesting conclusion is recently published in the Journal of Nuclear Medicine. The design of this study delivers interesting results besides those already mentioned.

First they compared healthy controls with depressed patients without medication for at least 2 weeks before undergoing SPECT. Single photon emission computed tomography (SPECT) is a nuclear medicine tomographic imaging technique using gamma rays. It is very similar to conventional nuclear medicine planar imaging using a gamma camera. However, it is able to provide true 3D information. Usually the gamma-emitting tracer used in functional brain imaging is 99mTc-HMPAO (hexamethylpropylene amine oxime). 99mTc is a metastable nuclear isomer which emits gamma rays which can be detected by a gamma camera. When it is attached to HMPAO, this allows 99mTc to be taken up by brain tissue in a manner proportial to brain blood flow, in turn allowing brain blood flow to be assessed with the nuclear gamma camera. Because blood flow in the brain is tightly coupled to local brain metabolism and energy use, the 99mTc-HMPAO tracer (as well as the similar 99mTc-EC tracer) is used to assess brain metabolism regionally.

Compared with healthy controls depressed patients had a significant lower regional cerebral blood flow (rCBF) before treatment over the frontal lobes and the subcortical nuclei (amygdala, caudate, thalamus and hypothalamus).The effect of antidepressants and ECT were compared with these baseline measures after treatment. Another SPECT was performed after 6 weeks of medication or completion of the ECT course.For those patients who responded to antidepressants, a significant increase in rCBF was found in the right parietal lobe of depressed patients. No perfusion changes were found in non-responders. No perfusion differences were found between medication responders and controls. In other words, responders on antidepressants had regained normal cerebral blood flow comparable to normal controls.

In contrast, rCBF was still lower in ECT responders than in controls, in the same region as before treatment as well as in the occipital and cerebellar regions. Especially this last finding is of interest since previous studies used the cerebellum as reference region for data analysis assuming the cerebellum had nothing to do with depression. The cerebellum was not traditionally considered a major contributor to the neurocircuitry of mood regulation. This assumption has to be refuted, cerebellar dysfunction is known to have an impact on cognition and affect.The fact that further reduction in rCBF in posterior brain regions occur after response to ECT could be a state phenomenon or a trait phenomenon. Long term studies are needed to document the course of rCBF changes.

This is the Talairach under-surface view showing the Prefrontal Inferior Orbital area at the top of the picture and the Temporal lobes in the middle of the picture. With Major Depression we see significant decreased blood flow to both of these areas of the Brain as is shown here.

Two giant competitors on the internet, Google and Microsoft, are competing on the issue of health. From pure gossip and circumstantial evidence it is suggested that Google would be interested in products to store and transport personal health information — information that is now often buried in paper files in doctors’ offices. Microsoft is looking at online offerings as well as software to find, retrieve and store personal health information on personal computers, cellphones and other kinds of digital devices — perhaps even a wristwatch with wireless Internet links some day.Read all about it:Wall Street JournalNew York TimesArticle on this blog

Why not, although safety seems an important issue with these developments and getting people to trust this service a major challenge.

Monday, August 13, 2007

A mental health pandemic and an inadequate Government response mean that over 3.5 million older people who experience mental health problems do not have satisfactory services and support, according to the final report from UK inquiry into Mental Health and Well Being in Later Life- a major independent inquiry by Age Concern.

As far as depression is concerned some conclusions from this report:1. One in four older people living in the community have symptoms of depression that are severe enough to warrant intervention.2. Only a third of older people with depression ever discuss it with their GP. 3. Only half of them are diagnosed and treated, primarily with anti-depressants. 4. Depression is the leading risk factor for suicide. Older men and women have some of the highest suicide rates of all ages in the UK.

Solutions from this report:1. Ending discrimination is the ﬁrst priority.2. Prioritising prevention is essential. Many mental health problems in later life can be prevented.3. Enabling older people to help themselves and each other is important.4. Improving current services is necessary.5. Facilitating change requires action in several areas.

I can't judge the political background of this report. As I learned from other sources mental health care for adults was in a deplorable state in the UK, probably improving in the recent years. So why shouldn't mental health care for the elderly have the same problem. As in most other western societies the percentage of elderly is increasing. About the solutions the only ominous sign is that there is no where any mentioning of funding for these changes. I am curious for the promise that Age Concern have agreed to audit responses to these recommendations and report on progress in 2009.As mentioned in an earlier article a part of the problem is the myth: the widespread defeatism which leads people to believe that mental health problems are an inevitable part of growing older and therefore nothing can be done.The full report as well as the press release, and a summary can be downloaded on a website.Newspapers also noticed the conclusions and have written articles about this report:TelegraphThe GuardianBBC NewsEvening Standard

Sunday, August 12, 2007

Electroconvulsive therapy during pregnancy should be performed with caution. In a case report a woman with a first time pregnancy received ECT during pregnancy. She was on maintenance ECT, every 2 weeks during her pregnancy she received ECT. She had a bipolar depression and was only partially responsive to conventional medical therapy.Fetal heart rates were recorded after each treatment but it was unclear how soon after the treatments and at what gestational age this testing began.At 36 weeks she had an elevated blood pressure and elevated protein on a 24-hour analysis. Labor was inducted because of preeclampsia. The newborn unexpectedly had severe neurological deficits associated with multiple brain infarcts.

Preeclampsia is a disorder that occurs only during pregnancy and the postpartum period and affects both the mother and the unborn baby. Affecting at least 5-8% of all pregnancies, it is a rapidly progressive condition characterized by high blood pressure and the presence of protein in the urine. Preeclampsia and other hypertensive disorders of pregnancy are a leading global cause of maternal and infant illness and death.

A cause and effect relationship between ECT and the inter hemispheric infarcts cannot be established. Whether ECT in this case led to tetanic uterine contractions causing a fetal bradycardia or possibly induced a fetal arrhythmia, resulting in fetal brain injury, is purely speculative. This chain of events does not seem likely because uterine contractions of sufficient strength to severely limit placental blood flow probably would have been noticed by the patient. Other possible explanations for this complication could be the preeclampsia, and medication use is not mentioned in this case report.

There are no prospective or controlled studies exploring the effects of ECT on pregnancy and the foetus. Many case reports have been written but these data do not provide evidence for definitive conclusions. According to the editorial in the same issue of this case report:

How likely is it that a study could be done to show a statistically significant association between ECT and fetal brain injury? If the rate of neurological impairment in an unexposed control group was in the range of 1 in 1,000 births and the rate of injury in infants of ECT-exposed women was 10 times higher, a prospective cohort study would have to enroll over 1,000 women in both the treated and control groups to demonstrate this difference with statistical significance. Given the rarity of ECT use in pregnancy, such a study would obviously not be feasible.

Nevertheless the American Psychiatric Association has published guidelines for management of a pregnant patient undergoing ECT.These guidelines are aimed at minimizing potential complications including aspiration and altered uteroplacental blood flow. Specific recommendations include

1. Consultation with an obstetrician before initiation of treatment.2. Treatments performed in a facility with immediate access to obstetric care for emergencies.3. Monitoring of fetal heart rate before and after treatments. Increase in monitoring at viability to include a non stress test with tocometry after treatments. Perform a Level 2 ultrasonography between 18 weeks and 22 weeks gestational age.4. Routine anesthetic measures (leftward tilt of trunk, adequate oxygenation, hydration, and muscle relaxation, nonparticulate antacid, consider intubation in the third trimester).

But above all ECT in pregnancy should only be used in cases of emergency in which any delay is life threatening or when medication has failed. Given the risks of non treatment of major depression and the undefined risk of ECT in pregnancy, we must, as the authors of this case report suggest, use drug therapy as our first-line approach to treatment. The neonatal risks with pharmacotherapy are real, but adverse effects generally do not have long-term consequences. Most importantly, in contrast to ECT, large-scale studies on drug therapy have been performed, allowing the risks to be quantified.

Saturday, August 11, 2007

Helen Mayberg found the switch that lifts depression in area 25, a spot deep in the cortex. This area is the key conduit of neural traffic between the thinking frontal cortex or forebrain and the central limbic region that plays a role in emotions and which appeared earlier in our evolutionary development. This area is overactive during depression or sadness. "Like a gate left open" she says. In contrast to this area both the frontal cortex and limbic region were less active as discovered with positron-emission tomography (PET)in depressed patients with Parkinson's disease compared to not depressed patients with this neurological disorder. Area 25 was also hyperactive in depressed patients without neurological disease. Patients that recovered form depression showed a rise in frontal activity and a calming in area 25. Area 25 also dampened when depressed patients responded to cognitive therapy.The whole story from the discovery of the relation between area 25 and depression to Deep Brain Stimulation (DBS) is told in a very readable chapter of the book: Best of the Brain from Scientific American, Mind, Matter, and Tomorrow's brain. Received this excellent book just a few days ago and read two chapters already in bed before going to sleep. I even finished the chapters before falling a sleep, that's a remarkable quality of the writers, usually it takes 10 minutes before I fall a sleep. I am very enthusiastic about this book so I had to tell you this story before reading the whole book and writing a complete review. Anyone with interest in the brain and results of recent research should read this book. It is easy to read. For the table of content please see The Dana Foundation. The Dana Foundation is a private philanthropy with principal interests in brain science, immunology, and arts education.Now back to the discovery of area 25 and DBS. With a group of researcher at the University of Toronto they sought a way to return the area back to normal activity. The group decided to try inserting electrodes in area 25 in a dozen severely depressed patients that had not responded to several antidepressants and ECT. A pair of electrodes and slender leads were slid in to area 25 after drilling a pair of nickel-size holes in the skull. A pacemaker was attached to the leads and placed under the collarbone. After turning the pacemaker on two thirds of the patients were completely recovered, never felt better.

Not only was there a new cure found for severely depressed patients not responding to the usual treatment but also our way of thinking about the brain has changed. The brain works as a system of coordinated functions that arise from different regions, rather than as a single unit.The chapter holds even more background information and interesting results with cognitive behavioural therapy and brain imaging, go get it.

Thursday, August 9, 2007

As mentioned before I use my blog for fun and staying up to date on the most important topics for my work. Since I am working as a psychiatrist in a University Hospital my interests are several. Depression, electroshock, education and research to name a few. Computers and internet not only for work but also to work as efficient as possible. GTD has no secrets for me anymore but I still waste a lot of time reading about the tips and tricks online.On one of my favourite blogs their was an article on 6 tips on staying Up-to-date in genetics, but genetics can be replaced by anything such as depression, GTD etc. The author added a few more suggestions of which I recognised many. I use these strategies to fill my blog and some more, but maybe one day I will reveal these tricks with the title: How does a shrink keep up?

The blog also has an interesting article how to use your blog to build an educational portfolio. An educational portfolio is a collection of research ideas, projects, presentations, manuscripts and published articles. A blog can be the perfect solution to building an electronic educational portfolio.

Among women with implants, a statistically significant 3-fold excesses of suicide and deaths from alcohol or drug dependence, as well as an excess of deaths from accidents and injuries consistent with substance abuse or dependence was found . The increased risk of suicide was not apparent until 10 years after implantation. This was found in a study of a nationwide cohort of 3527 Swedish women with cosmetic breast implants. This study had a mean follow-up of 18.7 years (range, 0.1-37.8 years). This number of deaths in this group was compared with the number expected among the age- and calendar-period-matched general female population of Sweden. The abstract of this study from the Annals of Plastic SurgeryThe excess of deaths from suicides, drug and alcohol abuse and dependence may be due to an underlying psychiatric condition among these women.From an article on Anxiety, Addiction and Depression Treatments

It needs to be made clear that the number of women whose causes of death could be linked to mental health concerns was small even within the study. The death rates were much higher than the population at large, but only future research will allow stronger conclusions. What is clear at this juncture is that more thorough pschological screening, both before and after surgery, might be appropriate. Elective cosmetic surgery should not be restricted or at all impeded by these screenings, but it would make sense that since we know there is a connection, that we use it to help improve the lives of those who may unknowingly be dealing with depression, anxiety or any number of mental health conditions.

Tuesday, August 7, 2007

On this site a clear and concise description of indications for electroshock (ECT) are given by NICE. NICE produces guidance in clinical practice. The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health in the United Kingdom. This information on electroconvulsive therapy is provided for use by the public and provides an explanation of the guidance.NICE was asked to look at the available evidence on electroconvulsive therapy and to provide guidance that will help the NHS in England and Wales decide when it should be used. This resulted in a nice pdf file with that information.

So now and then good information can be newly discovered on the web. The website from thirdage.com has very good information on depression. It is divided in an Indepth section with background information on depression and a section Living with depression. In this last section all kinds of everyday questions about depression are answered, such as:1. Depression in men, how is it different?2. Can folic acid help ease depression?3. How to choose a therapist4. Talk therapy or drug therapy: which is better.

The information is up to date, clearly written, objective and the authors are all MD's. The background of this website is hard to discover, if anyone finds a about section please let me know. I couldn't find any clues for conflicts of interests.

Monday, August 6, 2007

Continued treatment for 6 to 12 months beyond the acute phase of depression reduces the risk of relapse to 50%. Patients taking antidepressants during the continuation phase are at least 50% less likely to experience a relapse compared to patients with placebo. These continuation studies of antidepressants have used two different designs:

1. Patients are initially treated with an antidepressant, responders are then randomised to continue with the antidepressant or switched to placebo in a double-blind matter, both doctor and patient don't know what they are on.

2. Patients are treated with an antidepressant or placebo in a double blind fashion, responders to active treatment and placebo are continued on the treatment to which they initially responded.

The authors of this study in the Journal of Clinical Psychopharmacology hypothesised that the design of the study would impact on the likelyhood of relapse (getting a depression again). They speculated that the first design would result in more relapse since there is an obvious change in treatment, patients can be aware that they initially received active medication, and there is now a change that they will will be switched to placebo. Expectation of a positive outcome in this design would be lower.The authors conducted a meta-analysis of antidepressant continuation studies and compared the relapse rates using these 2 different designs. They identified 16 continuation studies of new-generation antidepressants, 11 using the first design and 5 using the second design.In the second design the frequency of relapse was lower compared to the studies using the first design. Also the difference between relapse with the antidepressant and placebo was greater with this design.The design of these studies has a significant impact on the absolute percentage of patients who relapse on both active medication and placebo, as well as an effect on the difference between relapse frequency between antidepressant and placebo.Other factors such as longer continuation phase, demographic factors, depression severity, broader definition of treatment response during the acute phase, and a broader definition of relapse did not explain the outcome of this meta-analysis. Drug withdrawal did not account for the difference in absolute relapse rates related to study design.

Treatment optimism for patients and raters may explain reduced relapse rates in the second design. Design should be taken into accoun when comparing results of continuation studies.

Impact of Study Design on the Results of Continuation Studies of Antidepressants. Brief Reports

Sunday, August 5, 2007

Highlighted areas in the picture above indicate increased activation associated with emotional auditory stimuli in 21 patients with Schizophrenia compared to 10 healthy controls. This result was obtained in a study with functional magnetic resonance imaging (fMRI) comparing 21 male patients with Schizophrenia and persistent auditory hallucinations. On average the patients started to hear voices at age 23. Their average illness duration was 15 years. The results showed functional abnormalities and corresponding gray matter deficits in several brain regions associated with regulating emotion and processing human voices. From medicalnewstoday.com

"The results showed abnormalities in specific areas of the brain associated with the capacity to process human voices," said lead author, Luis Mart'-Bonmat', M.D., Ph.D., chief of magnetic resonance in the Department of Radiology at Dr. Peset University Hospital in Valencia, Spain. Dr. Mart'-Bonmat' said. "Using MRI to mark brain regions that are affected in both structure and function will help pinpoint specific abnormalities associated with the disease and ultimately enable more effective treatment."

Saturday, August 4, 2007

38 of 50 patients refused randomisation beforehand because of fear of electroconvulsive therapy (ECT). An in depth interview showed that fear of brain damage by ECT played a major role. This recently published study was a feasibility study testing the efficacy and safety of ECT, prescribed in an earlier phase of treatment than last resort. This study would test the efficacy of ECT versus nortrityline among depressed elderly (> 59 years) who had not responded to sertraline, a selective serotonin reuptake inhibitor (SSRI).

In the Netherlands and most other European countries ECT remains underused and practised mostly as a last resort treatment. Especially depressed elderly could benefit from ECT in an earlier phase since delay may worsen their situation and outcome. Elderly who refuse to drink are at greater risk compared to adults, elderly usually have somatic comorbidity, elderly have more different drugs for somatic illness subscribed with dangers of interaction with antidepressants, elderly usually do not tolerate antidepressant due to side effects. All reasons why ECT might be a safer and more efficacious alternative. From retrospective studies efficacy of ECT in the depressed elderly are promising. From these studies it is expected that elderly might benefit more from ECT than adults.

The wrong assumption that ECT causes brain damage might be a vestige of the seventy's and the dark period of the anti psychiatry in the Netherlands in that same period. They probably still have the wrong scene from one flew over the cuckoo's nest in their head, the scene after the lobotomy which most people confuse with the result of ECT. Moreover the practice of ECT in that movie was how it was performed in early the 30's of the previous century. Due to this lack of knowledge a efficacious treatment is underused in this group.

Thursday, August 2, 2007

A 38 year old man in Minimal Conscious State (MCS) for 6 years after closed head injury after an assault was implanted bilateral Deep Brain Stimulation electrodes in his head with the tips in the central thalamus. The electrodes were turned off and on at random during different periods of 30 days. The patient was assessed by a neuro-rehabilitation team ignorant of the stimulation schedule. The patient was more alert during the DBS-on periods, he could use his limbs after instruction, and he could chew and swallow food when it was placed on his tongue. The observed improvements in arousal, motor control and behavioural persistence were due to the DBS. It seems there is another indication for DBS coming: chronic Minimal Conscious State with widely preserved brain structure and clear evidence of interactive behaviour (command following, verbalisation and inconsistent communication).Progression and long term outcome has to be assessed after this promising result.DBS is already used for Parkinson's disease when all other options failed and sporadically for depression, again when all other options have failed.From:Nature 448, 600-603 (2 August 2007) | doi:10.1038/nature06041; Received 13 April 2007; Accepted 22 June 2007

Wednesday, August 1, 2007

Analysis of more than 50,000 suicides in England and Wales between 1993 and 2003 showed the suicide rate rose when average daily temperatures topped 18C. The study appears in the British Journal of Psychiatry and is mentioned on the site of BBC News.The researchers discovered that a rise of 1 degree C (celsius) above 18 C increases the suicide rate with 4%.Proposed explanations:1. Higher degree of aggression and impulsivity due to the hot weather.2. The use of more alcohol in hot weather

If the hot weather starts suddenly the risk is higher than when people can adapt to the higher temperatures. Overall three-quarters of all suicides were by men and the largest number of suicides took place on Mondays. No spring or summer peak in suicide was found.

About Me

Dr Shock is a pseudonym for a psychiatrist working in a University Hospital. His main topics of interest are the treatment of depression and electro convulsive therapy. Other subjects for this personal blog are research, article reviews, book reviews and education. He loves computers and Internet.